Acknowledgement — My CBT

Notice of Privacy Practices Receipt & Acknowledgement of Notice

Notice of Privacy Practices Receipt & Acknowledgement of Notice

Patient/Client Name

First Name

Last Name

Date of Birth

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Signature of Patient/Client (type full name)

I hereby acknowledge that I have received and have been given an opportunity to read a copy of the Notice of Privacy Practices for Julie Osborn, LCSW, Psy.D. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Julie L. Osborn, LCSW, Psy.D, 6 Venture #340, Irvine, CA 92618, Phone: 949-224-3136

Date

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Signature of Parent, Guardian, or Personal Representative*

First Name

Last Name

Date

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DD

YYYY

* If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).

Patient/Client Refuses to Acknowledge Receipt

Signature of Julie Osborn, LCSW, Psy.D (type full name)

6 Venture #340, Irvine, CA 92618

Date

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DD

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